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Discusses benign paroxysmal positional vertigo (BPPV). Distinguishes between dizziness and a feeling of spinning (vertigo). Covers how it is diagnosed. Discusses treatment with head exercises (Epley and Semont maneuvers) and medicines.

Benign Paroxysmal Positional Vertigo (BPPV)

Topic Overview

What is benign paroxysmal positional vertigo (BPPV)?

Vertigo is the feeling that you are spinning or the
world is spinning around you. Benign paroxysmal positional vertigo is caused by
a problem in the
inner ear. It usually causes brief vertigo spells that come and go.

For some people, BPPV goes away by itself in a few weeks. But it can come
back again.

BPPV is not a sign of a serious health
problem.

What causes BPPV?

Benign paroxysmal positional
vertigo (BPPV) is caused by a problem in the inner ear. Tiny calcium "stones"
inside your inner ear canals help you keep your balance. Normally, when you
move a certain way, such as when you stand up or turn your head, these stones
move around. But things like infection or inflammation can stop the stones from
moving as they should. This sends a false message to your brain and causes the vertigo.

What are the symptoms?

The main symptom is a
feeling that you are spinning or tilting when you are not. This can happen when
you move your head in a certain way, like rolling over in bed, turning your
head quickly, bending over, or tipping your head back.

BPPV
usually lasts a minute or two. It can be mild, or it can be bad enough to make
you feel sick to your stomach and vomit. You may even find it hard to stand or
walk without losing your balance.

How is BPPV diagnosed?

Your doctor can usually tell that you have BPPV by asking you questions about your vertigo and doing a physical exam. You may have a test where your doctor watches your eyes while turning your head and helping you lie back. This is called
the Dix-Hallpike test.

There are other things that can cause
vertigo, so if your doctor doesn't think you have BPPV, you may have other tests too.

How is it treated?

Your doctor can usually do one of two procedures in the office that works for most cases of BPPV. These procedures are called the Epley maneuver and the Semont maneuver. If you don't want treatment or if treatment doesn't work, BPPV usually goes away by
itself within a few weeks. Over time, your brain will likely get used to the
confusing signals it gets from your inner ear. Either way, you can do some simple
exercises that train your brain to get used to
the confusing vertigo signals.

Medicine can help with severe
nausea and vomiting caused by your vertigo. But using this kind of medicine
can also make BPPV take longer to go away. Only you know whether you feel sick
enough that it is worth it to take medicine (and possibly have vertigo
longer).

Be extra careful so that you don't hurt yourself or
someone else if you have a sudden attack of vertigo.

Do not drive or cycle if there is any chance that vertigo could
strike and make you lose control. (This depends on what kind of movement
triggers vertigo for you.)

At home, keep floors and walkways free of clutter so you don't
trip.

Avoid heights.

Don't use tools or machines that could be dangerous if you
suddenly get dizzy or lose your balance.

Cause

Benign paroxysmal positional vertigo
(BPPV) is caused by a problem in the inner ear. Tiny calcium "stones" inside
your inner ear canals help you keep your balance. Normally, when you move a
certain way, such as when you stand up or turn your head, these stones move
around. But things like infection or inflammation can stop the stones from
moving as they should. This sends a false message to your brain and causes the vertigo.

Symptoms

The main symptom of
benign paroxysmal positional vertigo (BPPV) is the
feeling that you or your surroundings are spinning, whirling, or tilting. This
sensation is called vertigo.

It is important to understand the
difference between vertigo and dizziness. People often
use those two terms as if they meant the same thing. But they are different
symptoms, and they may point to different problems.

Vertigo is the feeling that you are spinning or the world is
spinning around you. It happens when your body's
balance sensory systems disagree about what kind of
movement they sense. You may find it hard to walk or stand. You may even lose
your balance and fall. If your vertigo is bad enough, you may also have nausea
and vomiting.

Dizziness is not a feeling that you are spinning. It is a woozy
or unsteady feeling.

To find out whether your vertigo is caused by BPPV, your
doctor will want to find out what causes it, how bad it is, and how long it
lasts. With BPPV:

Tilting the head, looking up or down, rolling over in bed, or
getting in and out of bed causes vertigo.

It begins a few seconds after you move your head.

It usually lasts less than a minute. The spinning sensation may
be mild, or it may be bad enough to cause nausea and vomiting.

Vertigo becomes less noticeable each time you repeat the same
movement. After 3 or 4 repeats, the movement may no longer cause vertigo.
Several hours may pass before the same movement again causes vertigo.

What Happens

Benign paroxysmal positional vertigo (BPPV) causes a
whirling, spinning sensation even though you are not moving. If the vertigo is
bad, it may also cause nausea or vomiting. The vertigo attacks happen when you
move your head in a certain way, such as tilting it back or up or down, or by
rolling over in bed. It usually lasts less than a minute. Moving your head to
the same position again may trigger another episode of vertigo.

BPPV often goes away without treatment. Until it does, or is successfully
treated, it can repeatedly cause vertigo with a particular head movement.
Sometimes it will stop for a period of months or years and then suddenly come
back.

What Increases Your Risk

Scientists think you're more
likely to develop
benign paroxysmal positional vertigo (BPPV) if you
have one of these conditions:

You are an older adult.

You have a head injury.

You have an
inflammation of the inner ear or of the nerve that
connects the inner ear to the brain, a condition called
vestibular neuritis.

You have ear surgery.

If you've had one episode of vertigo caused by BPPV, you
are likely to have more.

When To Call a Doctor

Call 911 or other emergency services immediately if you have
vertigo (a spinning sensation) and:

You passed out (lost consciousness).

You have symptoms of a stroke, such as:

Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.

Sudden vision changes.

Sudden trouble speaking.

Sudden confusion or trouble understanding simple statements.

Sudden problems with walking or balance.

A sudden, severe headache that is different from past headaches.

You have chest pain.

You have a headache, especially if you also have a stiff
neck and fever.

You have sudden hearing loss.

You have numbness or tingling that does not go away, anywhere on
your body.

You have vomiting that doesn't stop.

You had a recent head injury.

Call your doctor now or seek immediate care
if:

You have an attack of vertigo that is different from those
you have had before or from what your doctor told you to
expect.

You need medicine to control nausea and vomiting caused by
severe vertigo.

Call your doctor to schedule an appointment if:

This is the first time you have had an attack of vertigo.

You have a low-pitched roaring, ringing, or hissing sound in your
ear, especially if you have not had this before. This is called
tinnitus.

You have frequent or severe episodes of vertigo that interfere
with your activities.

Watchful waiting

If your symptoms suggest
benign paroxysmal positional vertigo (BPPV), watchful
waiting may be appropriate. Over time BPPV may go away on its own. But treatment with a simple procedure in your doctor's office (either the Epley or Semont maneuver) can usually stop your vertigo right away. Talk to your doctor. If your vertigo
interferes with your normal daily activities or causes nausea and vomiting, you
may need treatment.

Who to see

The following health professionals are able to diagnose
and treat BPPV and the causes of vertigo:

Exams and Tests

Benign paroxysmal positional vertigo (BPPV) is diagnosed with a physical exam and your
medical history. But diagnosing the cause of the
spinning, whirling sensation of
vertigo can be difficult. Several diseases, the side
effects of medicines, and head injuries can also cause vertigo.

A
Dix-Hallpike test may be done to help your doctor find
out the cause of your vertigo. During this test, he or she will carefully
observe any involuntary eye movements. This will help your doctor know whether
the cause of your vertigo is inside your brain, your inner ear, or the nerve
connected to your inner ear. The Dix-Hallpike test also can help your doctor
find out which ear is affected.

If your symptoms or the results of your exam make your doctor think you don't have BPPV, other tests may be done:

Electronystagmography, which attaches small wires to
your face that measure eye movements. It looks for the special eye movements
that happen when the inner ear is stimulated. The pattern of eye movements can
point to the location of the cause of the vertigo, such as the inner ear or the
central nervous system.

Hearing testing to detect hearing loss. A special
hearing test can determine whether the nerve from the inner ear to the brain is
working correctly. Hearing loss with vertigo usually points to a problem other
than BPPV, such as
Ménière's disease or
labyrinthitis.

Treatment Overview

Benign paroxysmal positional vertigo (BPPV) may go away in a few weeks by itself. If
treatment is needed, it usually consists of head exercises (Epley and Semont maneuvers). These exercises will move the particles out of the
semicircular canals of your
inner ear to a place where they will not cause vertigo.

Over time, your brain may react less and less to the confusing signals
triggered by the particles in the inner ear. This is called
compensation. Compensation occurs most quickly if you
continue normal head movements, even though doing so causes the whirling
sensation of
vertigo. A
Brandt-Daroff exercise may also be done to speed the
compensation process.

Medicines called
vestibular suppressants (such as
antihistamines,
sedatives, or
scopolamine) may be tried if your
symptoms are severe. But using medicines to control vertigo often extends the
time needed for compensation to occur.

Antiemetic medicines
may also be used to reduce nausea and vomiting that can occur with
vertigo.

In rare cases, surgery may be used to treat BPPV.

Prevention

In most cases,
benign paroxysmal positional vertigo (BPPV) cannot be
prevented. But some cases may result from head injuries. Wearing a helmet
when bicycling, motorcycling, playing baseball, or doing other sports
activities can protect you from a head injury and BPPV.

Home Treatment

You can reduce the whirling or spinning
sensation of
vertigo when you have
benign paroxysmal positional vertigo (BPPV) by taking
these steps:

Use two or more pillows at night.

Avoid sleeping on your side with the ear that's causing the problem
facing down.

Get up slowly in the morning and sit on the edge of the bed for a
moment before standing.

Avoid leaning over to pick things up or tipping your head far
back to look up.

Be careful about reclining, such as when you are in the dentist's
chair or having your hair washed at a hair salon.

Be careful about playing sports that require you to turn your
head, lean over, or lie flat on your back.

You can also help yourself by doing balance exercises and
taking safety precautions.

Brandt-Daroff exercises can be done at home to help your brain get used to the abnormal balance signals
triggered by the particles in the inner ear.

Balance exercises for vertigo, such as standing with
your feet together, arms down, and slowly moving your head from side to side,
may help you keep your balance and improve symptoms of vertigo.

Staying as active as
possible usually helps the brain adjust more quickly. But that can be hard to
do when moving is what causes your vertigo. Bed rest may help, but it usually
increases the time it takes for the brain to adjust.

Medications

Medicines do not cure
benign paroxysmal positional vertigo (BPPV). But they
may be used to control severe symptoms, such as the whirling, spinning
sensation of
vertigo and the nausea and vomiting that may
occur.

Medicine choices

Medicines to reduce the whirling sensation of vertigo are
called vestibular suppressants. They include:

Antihistamines, such as meclizine (Antivert).

Scopolamine (Transderm-Scop).

Sedatives, such as clonazepam
(Klonopin).

Antiemetic medicines, such as promethazine (Promethegan), may be used if you have severe nausea or
vomiting.

What to think about

Medicines that calm the inner
ear (vestibular suppressants) may also slow down the brain's ability to adjust
to the abnormal balance signals triggered by the particles in the inner ear.
They should be taken only to control severe symptoms.

Surgery

Ear surgery is an option for treating
benign paroxysmal positional vertigo (BPPV) only in
severe cases when other treatments have not worked.

Other Treatment

Exercises are used to treat
benign paroxysmal positional vertigo (BPPV). These
exercises help the particles in the semicircular canals of your
inner ear move around, so that they don't cause vertigo. Although the
exercises usually stop the vertigo for months or years, the problem may return
and cause your symptoms to come back.

Other treatment choices

Exercises that may be used to treat BPPV include:

Epley maneuver and Semont maneuver. These
exercises often cure BPPV by moving the particles in your inner ear so that
they do not affect your balance. During these exercises, your doctor will help
you hold your head in a series of positions. Often, one treatment is enough.
You may be taught to do these exercises on your own at home.

Brandt-Daroff exercise. This exercise may be tried if
the Epley or Semont maneuvers do not work. During this exercise, you
will repeatedly go from a sitting position to a lying position until the
vertigo stops. This exercise may help speed your brain's ability to adjust to
the conflicting balance signals it is getting. You need to do these exercises
several times a day for weeks for them to work.

What to think about

These exercises can get rid of
BPPV symptoms. The Epley and Semont maneuvers usually are more
comfortable than the Brandt-Daroff exercise, and they work faster—in one or two
treatments rather than being repeated several times a day for weeks. So these
maneuvers have become the first line of treatment.1

Other Places To Get Help

Organizations

American Hearing Research Foundation

Web Address:

www.american-hearing.org

National Institute on Deafness and Other Communication Disorders (U.S.)

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